Four Implications of the AHCPR Guidelines

By Chester Wilk, DC

The loud "yahoo" heard coming from Chicago recently wasn't an air raid, or Martians landing, but me yelling after recognizing the four areas in the guidelines of the Agency for Health Care Policy and Research (Acute Low Back Pain Problems in Adults) that would have a major impact on chiropractic.

If this doesn't excite you nothing will. I believe that this is the greatest thing that has happened to chiropractic and the people it has served for 100 years. It's befitting that it should happen during our centennial year. Let's take these four points by the numbers:

I. We can now say that the US government's Depart. of Health and Human Services, via the AHCPR, says spinal manipulation is the treatment of choice and should be tried before surgery; that spinal manipulation has more scientific data supporting its merit than medicine for its treatments for acute low back pain. While it is true that it does not specifically refer to chiropractic, let's look at some hard facts. The RAND Corporation says that chiropractors conduct 94 percent of all spinal manipulations in America. The US government, realizing that science was not at the root of so many of the low back treatments, decided it was time to gather a group of world leading experts on back pain and go through the tens of thousands of published research articles. The group included medical, osteopathic and chiropractic doctors whose collective job was to gather the very best studies conducted under the most rigorous scientific methodologies. When this was accomplished, spinal manipulation was the undisputed champion for acute low back pain. We were front and center; surgery was criticized and left out in the cold. The surgeons were understandably perplexed.

Some might say, "Oh no, not another low back study. We can do more than that." You'll not get any argument from me on that point, but let's consider some facts and how getting a study on low back pain is inescapable.

Low back disc surgery is the third most common surgery in America. LBP is the second most common ailment that brings patients into doctors' offices -- second only to colds. LBP is the most expensive ailment crippling our nation. It costs America $20 billion a year. Combine that with related costs of loss of work, hiring replacements who cannot function as efficiently as the original employees, and you can add another $60 billion dollars. LBP is an $80 billion dollar a year health care problem facing America. Is there any wonder that the US government seeing the crisis chose to select LBP as a major target for evaluation? If everyone that should go to chiropractors with LBP came to us, we could not handle the volume: we'd need 10 times more chiropractors just for LBP. It's not that we are being narrowed into one type of ailment; it's just that it is so prevalent and no other profession compares with our effectiveness. Forget the osteopaths; the American Osteopathic Assoc. reported as late as April of 1993 that spinal manipulation was a "dead art" within osteopathy. And going to any physical therapists is a joke if you evaluate how grossly inferior their training is compared to our sophistication. It's no contest. If there are any groups taking weekend courses on spinal manipulation and striving to use them in your state, you should embrace them and tell them you welcome their attempt. However tell them that they must first go back to school and get some real training at a chiropractic college. After they get their chiropractic degree, they should be able to manipulate the spine. Doing any less will bastardize the art of good spinal manipulation.

II. There are some 250,000 to 350,000 disc operations done yearly. "CBS News" said that 80,000 of them were unnecessary. I think most of us would agree that figure is probably much too low, while other studies are suggesting that most of the disc surgeries were not necessary. That means that well over 100,000 people every year become a medical statistic of unnecessary disc surgeries. That means that in the last five years we may have over a half-million people walking around sorry that they were operated on and are probably quite unhappy with their surgeon. Although they may be angry they have felt it was too late, and they will just have to live with it. But will they? Let's take this a bit further.

As you probably know I have been advocating for some time that chiropractors should become more vocal by approaching radio and television stations and motivating the stations to want them as a guest on a talk show. Chiropractors should know what to say and how to say it for power, impact, authority and believability. Guests on talk shows do no pay for the exposure and their exposure has far superior credibility over paid advertisements. It's the best PR in the world and it's free.

Let's suppose an army of a thousand chiropractor nation-wide got on talk shows and mentioned how no less authority than the AHCPR, under the authority of the Dept. of Health and Human Services, went through tens of thousands of research articles and studies and found that spinal manipulation was clearly the superior approach, and how surgery should not be done until conservative methods were tried first. And let's suppose these hundreds of thousands of unhappy and disgruntled victims of quick surgery were advised of what the government's position was on surgery. And let's suppose these chiropractors began talking about how government guidelines may be violated by surgeons who too quickly elect to use the knife before trying government recommended conservative approaches. Of course guidelines are not standards which must be followed. However, backed by the US government and tens of thousands of studies whittled down to the absolute best, means that the guidelines carry a very compelling case for potential inappropriate surgery. Let's suppose these victims of possible indiscrete surgeries started calling their lawyers and considered filing malpractice lawsuits on a contingency basis. Let's suppose the surgeons began having a rash of lawsuits across the country. How do you think the surgeons would react knowing that many of the suits were precipitated because of these chiropractors talking about them on all these talk shows? Put yourself in their shoes. They would probably be in a frenzy. They would probably be saying, "Those chiropractic SOBs are causing massive lawsuits against us" (SOB, of course, meaning sweet old backdocs).

If any of them approach me and suggest that I'm causing lawsuits, I'll simply tell them that it is high time that they begin acting responsibly. If they act irresponsibly and want to dig themselves into a hole, that's their problem. I'll just throw the dirt on top. They did it to themselves. Once this happens then maybe the hospitals and HMOs will wake up. We now have the super megaton bomb; all we need is the delivery system. A 1,000 appropriately trained chiropractors is the answer. This abomination to health care must be corrected.

III. Wait until the AHCPR does their study on headaches. I guarantee it will literally blow away anything the medics have to offer. We will suddenly become "headache doctors." That will be a new twist. I have spoken with many chiropractors in my travels, and the anecdotal reports I get from headache patients is not coincidental. I offered my services to a local hospital to allow me to treat a test group of chronic medically unresponsive headache patients who have had all the tests and treatments but no results. They declined, although I enclosed several case histories of my chronic headache sufferers and their telephone numbers for verification. I took it to the local newspaper and they put my story on the front page with a picture of me flanked by two of my smiling patients.

IV. The final implication is that now the researchers will begin to realize that chiropractic is not limited to musculoskeletal ailments. Although it may not be as dramatic, chiropractic has shown promise in other less common ailments. Perhaps the reason spinal manipulation is not considered is because the ailments themselves are not as prevalent and costly as back pain. Once this happens people will begin thinking in terms of chiropractic improving the quality of life of the patient. When this happens then we will have fully arrived.

As for hospitals and HMOs, the public pressure can become so massive by that time that hospitals and HMOs will be embracing chiropractors -- or face the wrath of some very angry and unhappy health care recipients who will call their lawyers. It is conceivable that chiropractic could find itself in all hospitals and HMOs in the not too distant future. Now you can understand why the big "yahoo."

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